Measuring the value of solidarity: The abem financial assistance program for out-of-pocket payments on pharmacy medicines in Portugal

OBJECTIVE

Out-of-pocket payments for prescribed medicines are still comparatively high in Portugal. The abem program was launched in Portugal in May 2016 to aid vulnerable groups by completely covering out-of-pocket costs of prescribed medicines in community pharmacies. This study assesses the impact of the program on poverty and catastrophic health expenditures.

METHODS

A longitudinal study was carried out with the analysis of several program databases (from the beginning of the program in May 2016 to September 2018) covering the cohorts of beneficiaries, daily data on medicines dispensed, social referencing entities, and solidarity pharmacies. The study provides estimates of standard poverty measures (intensity and severity) as well as the incidence of catastrophic health expenditures.

RESULTS

More than 6000 beneficiaries were supported (56.8% female, 34.7% aged 65 or over), encompassing 127,510 medicines (mainly nervous system and cardiovascular system) with an average 26.9% co-payment (payments totalling €1.5 million). The program achieved substantial reductions in poverty (3.4% in intensity, 5.6% in severity), and eliminated cases with catastrophic health expenditures in medicines that would have affected 7.5% of the beneficiaries.

CONCLUSIONS

Findings confirm a continuous increase in the number of beneficiaries, enabling access to medicines especially for the vulnerable elderly, and a sizable impact on eliminating out-of-pocket payments for medicines in the target population.

Histology-Agnostic Drugs: A Paradigm Shift-A Narrative Review

Cancer diagnosis and therapeutics have been traditionally based on pathologic classification at the organ of origin. The availability of an unprecedented amount of clinical and biologic data provides a unique window of opportunity for the development of new drugs. What was once treated as a homogeneous disease with a one-size-fits-all approach was shown to be a rather heterogeneous condition, with multiple targetable mutations that can vary during the course of the disease. Clinical trial designs have had to adapt to the exponential growth of targetable mechanisms and new agents, with ensuing challenges that are closer to those experienced with rare diseases and orphan medicines. To face these problems, precision/enrichment and other novel trial designs have been developed, and the concept of histology-agnostic targeted therapeutic agents has emerged. Patients are selected for a specific agent based on specific genomic or molecular alterations, with the same compound used to potentially treat a multiplicity of cancers, granted that the actionable driver alteration is present. There are currently approved drugs for such indications, but this approach has raised issues on multiple levels. This review aims to address the challenges of this new concept and provide insights into possible solutions and frameworks on how to tackle them.

Metodologia Prática de Gestão do Programa Choosing Wisely Portugal: Escolhas Criteriosas em Saúde

N/a.

Broadening risk factor or disease definition as a driver for overdiagnosis: A narrative review

Medical overuse-defined as the provision of health services for which potential harms exceed potential benefits-constitutes a paradigm of low-value care and is seen as a threat to the quality of care. Value in healthcare implies a precise definition of disease. However, defining a disease may not be straightforward since clinical data do not show discrete boundaries, calling for some clinical judgment. And, if in time a redefinition of disease is needed, it is important to recognize that it can induce overdiagnosis, the identification of medical conditions that would, otherwise, never cause any significant symptoms or lead to clinical harm. A classic example is the impact of recommendations from professional societies in the late 1990s, lowering the threshold for abnormal total cholesterol from 240 mg/dl to 200 mg/dl. Due to these changes in risk factor definition, literally overnight there were 42 million new cases eligible for treatment in the United States. The same happened with hypertension-using either the 2019 NICE guidelines or the 2018 ESC/ECC guidelines criteria for arterial hypertension, the proportion of people overdiagnosed with hypertension was calculated to be between 14% and 33%. In this review, we will start by discussing resource overuse. We then present the basis for disease definition and its conceptual problems. Finally, we will discuss the impact of changing risk factor/disease definitions in the prevalence of disease and its consequences in overdiagnosis and overtreatment (a problem particularly relevant when definitions are widened to include earlier or milder disease).

Lost in transition: a systematic review of the association between unemployment and mental health

BACKGROUND

Unemployment can involve financial strain and major psychosocial challenges. Integration of the existing evidence is needed to better characterize the association between unemployment and mental health, independently of macroeconomic contexts.

AIMS

Main objectives of this study: (a) review, integrate, and summarize evidence about the association between unemployment and anxiety disorders, mood disorders, and suicidal behaviour, and (b) identify variables affecting this association.

METHOD

Systematic review of literature following PRISMA guidelines. PubMed, Web of Science, SciELO, RCAAP, and Cochrane Library databases were searched. Quantitative empirical studies on the association between unemployment and mental illness of community-based samples were included. The quality of the evidence provided in the studies was assessed following pre-defined methodological criteria.

RESULTS

Overall, 294 articles were considered eligible. In total, 55.7% of the studies were conducted in Europe; 91.4% supported a positive association between increased unemployment rates and anxiety, mood disorders, or suicidal behavior. Men and young adults were most severely affected by unemployment. Education and social support were found to buffer the negative outcomes of job loss.

CONCLUSIONS

Unemployment was inversely associated with mental health irrespectively of the economic context; unemployed individuals were more vulnerable to commit suicide and suffer from anxiety and mood disorders.

Pharmacy interventions on COVID-19 in Europe: Mapping current practices and a scoping review

Background

The COVID-19 pandemic has put community pharmacists at the frontline of prevention, preparedness, response, and recovery efforts. Pharmacies had to reorganize and implement several different interventions and measures within a very short time frame.

Objectives

1) To map the current reported practice and trends and to review the literature on pharmacy-based interventions on COVID-19 provided in Europe; 2) To identify knowledge gaps and future avenues for pharmacy research, policy, and practice in response to public health emergencies.

Methods

We used a mixed methods approach combining country mapping of current practices of pharmacy interventions on COVID-19 reported by pharmacy associations in Europe with a scoping review of published literature.

Results

We mapped current practices on 31 pharmacy interventions on COVID-19 in 32 countries in Europe. Almost all preventive measures to reduce health risks have been provided in most countries. Other frequent interventions reflected preparedness for stockpiling, increased demand for services and products, and important patient care interventions exceeding dispensing role. Expanded powers granted to pharmacies and legislation passed in view of COVID-19 enabled services that improve access to medicines and relevant products, patient screening and referral including point-of-care antigen testing, support to vulnerable patients, and COVID-19 vaccination. We identified 9 studies conducted in pharmacies in 7 countries in Europe. Most studies are cross-sectional and/or descriptive. Pharmacy associations played an important supporting role by developing and updating guidance and emergency plans to assist community pharmacists.

Conclusions

A wide array of pharmacy interventions on COVID-19 was implemented in several countries within a very short time frame. Research on pharmacy interventions on COVID-19 is still in its infancy but confirmed the wide array of interventions provided and expanded powers granted to pharmacies. These findings may provide a significant impact to improve pharmacy research, policy, and practice in response to future public health emergencies in Europe and globally.

[Analysis of the Cochrane Review: Antiplatelet Agents for Preventing Pre-Eclampsia and Its Complications. Cochrane Database Syst Rev. 2019;10:CD004659.]

Pre-eclampsia is associated with deficient intravascular production of prostacyclin, a vasodilator, and excessive production of thromboxane, a vasoconstrictor and stimulant of platelet aggregation. These observations led to the hypotheses that antiplatelet agents, low-dose aspirin in particular, might prevent or delay development of pre-eclampsia. This Cochrane review aimed to assess the effectiveness and safety of antiplatelet agents, such as aspirin and dipyridamole, when given to women at risk of developing preeclampsia. A systematic review of literature was carried out by searching the following databases up to September 2019: Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP), and reference lists of retrieved studies. Seventy-seven trials were included, including 40 249 women at risk of developing pre-eclampsia. About 80% of these women were evaluated in nine of the 77 trials included, with eight of these nine trials providing individual data. Interventions were administration of an antiplatelet agent, and comparisons were either placebo or no antiplatelet. The present review provides high-quality evidence that administering low-dose aspirin (50 - 150 mg) to pregnant women led to small-to-moderate benefits, including reductions in the risk of pre-eclampsia, preterm birth, small-for-gestational age fetus, and fetal or neonatal death. Overall, administering antiplatelet agents to 1000 women led to 20 fewer pregnancies with serious adverse outcomes.

Health Behavior and Planetary Health

Abstract. Health and environmental psychology have long been walking side by side. These two disciplines of psychology have imported and applied common psychological frameworks and each of them developed specific theories and methodologies. At a time when humankind faces tremendous challenges ahead (climate change, global warming, ocean sickness, the reemergence of infections pandemics), environmental health is more and more a crucial domain of research. Both environmental psychology and health psychology need to be engaged in environmental health issues in order to enhance planetary health. Environmental psychology traditional fields of research provide understanding about how natural or constructed environments impact human identity, attitudes, and behaviors (more recently, environmental psychology is also investing in determinants of pro-environmental behaviors). On the other hand, health psychology has an extensive comprehensive framework about how to promote healthy habits (i.e., automatically activated behaviors). We live in a global and extremely complex and interconnected world, which promotes syndemic phenomena (several interactive epidemics sharing common etiological factors), also resulting in accelerated depletion of natural resources. This current scenario might justify the development of an Environmental Health Psychology discipline, joining together tools from both environmental psychology and health psychology in a synergic and strategic way.

Functional Health Literacy: Psychometric Properties of the Newest Vital Sign for Portuguese Adolescents (NVS-PTeen)

Self-management of health requires skills to obtain, process, understand, and use health-related information. Assessment of adolescents’ functional health literacy requires valid, reliable, and low-burden tools. The main objective of this study was to adapt and study the psychometric properties of the Newest Vital Sign for the Portuguese adolescents’ population (NVS-PTeen). Classic psychometric indicators of reliability and validity were combined with item response theory (IRT) analyses in a cross-sectional survey, complemented with a 3-month test-retest assessment. The NVS-PTeen was self-administered to students enrolled in grades 8 to 12 (12 to 17 years old) in a school setting. Overall, 386 students (191 girls) from 16 classes of the same school participated in the study (mean age = 14.5; SD = 1.5). Internal reliability of the NVS-PTeen was α = 0.60. The NVS-PTeen total score was positively and significantly correlated with Portuguese (r = 0.28) and mathematics scores (r = 0.31), school years (r = 0.31), and age (r = 0.19). Similar to the original scale (for the U.S.), the NVS-PTeen is composed of two dimensions, reading-related literacy and numeracy. Temporal reliability is adequate, though with a learning effect. IRT analyses revealed differences in difficulty and discriminative capacity among items, all with adequate outfit and infit values. Results showed that the NVS-PTeen is valid and reliable, sensible to inter-individual educational differences, and adequate for regular screening of functional health literacy in adolescents.

The burden of atherosclerosis in Portugal

Aims

This article sought to estimate the burden of disease attributable to atherosclerosis in mainland Portugal in 2016.

Methods and results

The burden of atherosclerosis was measured in disability-adjusted life years following the latest 2010 Global Burden of Disease (GBD) methodology. Disability-adjusted life years were estimated as the sum of years of life lost (YLL) with years lived with disability (YLD). The following clinical manifestations of atherosclerosis were included: ischaemic heart disease (IHD) (including acute myocardial infarction, stable angina, and ischaemic heart failure), ischaemic cerebrovascular disease (ICVD), and peripheral arterial disease (PAD). Years of life lost were estimated based on all-cause mortality data for the Portuguese population and mortality due to IHD, ICVD, and PAD for the year 2016 sourced from national statistics. Standard life expectancy was sourced from the GBD study. Years lived with disability corresponded to the product of the number of prevalent cases by an average disability weight for all possible combinations of disease. Prevalence data for the different clinical manifestations of atherosclerosis were sourced from epidemiological studies. Disability weights were sourced from the published literature. In 2016, 15 123 deaths were attributable to atherosclerosis, which corresponded to 14.3% of overall mortality in mainland Portugal. Disability-adjusted life years totalled 260 943, 75% due to premature death (196 438 YLL) and 25% due to disability (64 505 YLD).

Conclusion

Atherosclerosis entails a high disease burden to society. A large part of this burden would be avoidable if evidence-based effective and cost-effective interventions targeting known risk factors, from prevention to treatment, were implemented.

[Reply to a Comment Published on Acta Med Port 2020; May 25; doi:10.20344/amp.14155 about the Article Published on Acta Med Port 2020; Apr 27; doi:10.20344/amp.13928]

N/a.

The Role of Health Preconditions on COVID-19 Deaths in Portugal: Evidence from Surveillance Data of the First 20293 Infection Cases

BACKGROUND

It is essential to study the effect of potential co-factors on the risk of death in patients infected by COVID-19. The identification of risk factors is important to allow more efficient public health and health services strategic interventions with a significant impact on deaths by COVID-19. This study aimed to identify factors associated with COVID-19 deaths in Portugal.

METHODS

A national dataset with the first 20,293 patients infected with COVID-19 between 1 January and 21 April 2020 was analyzed. The primary outcome measure was mortality by COVID-19, measured (registered and confirmed) by Medical Doctors serving as health delegates on the daily death registry. A logistic regression model using a generalized linear model was used for estimating Odds Ratio (OR) with 95% confidence intervals (95% CI) for each potential risk indicator.

RESULTS

A total of 502 infected patients died of COVID-19. The risk factors for increased odds of death by COVID-19 were: sex (male: OR = 1.47, ref = female), age ((56-60) years, OR = 6.01; (61-65) years, OR = 10.5; (66-70) years, OR = 20.4; (71-75) years, OR = 34; (76-80) years, OR = 50.9; (81-85) years, OR = 70.7; (86-90) years, OR = 83.2; (91-95) years, OR = 91.8; (96-104) years, OR = 140.2, ref = (0-55)), Cardiac disease (OR = 2.86), Kidney disorder (OR = 2.95), and Neuromuscular disorder (OR = 1.58), while condition (None (absence of precondition); OR = 0.49) was associated with a reduced chance of dying after adjusting for other variables of interest.

CONCLUSIONS

Besides age and sex, preconditions justify the risk difference in mortality by COVID-19.

Reply to a Comment about the Article Published in Acta Med Port 2020; Apr 27; doi:10.20344/amp.13928

N/a.

Costs and consequences of the Portuguese needle-exchange program in community pharmacies

Background

Needle-exchange programs (NEPs) reduce infections in people who inject drugs. This study assesses the impact community pharmacies have had in the Needle-Exchange Program in Portugal since 2015.

Methods

Health gains were measured by the number of human immunodeficiency virus (HIV) and hepatitis C virus (HCV) infections averted, which were estimated, in each scenario, based on a standard model in the literature, calibrated to national data. The costs per infection were taken from national literature; costs of manufacturing, logistics and incineration of injection materials were also considered. The results were presented as net costs (i.e., incremental costs of the program with community pharmacies less the costs of additional infections avoided).

Results

Considering a 5-year horizon, the Needle Exchange Program with community pharmacies would account for a 6.8% (n = 25) and a 6.5% reduction (n = 22) of HCV and HIV infections, respectively. The present value of net savings generated by the participation of community pharmacies in the program was estimated at €2,073,347. The average discounted net benefit per syringe exchanged is €3.01, already taking into account a payment to community pharmacies per needle exchanged.

Interpretation

We estimate that the participation of community pharmacies in the Needle Exchange Program will lead to a reduction of HIV and HCV infections and will generate over €2 million in savings for the health system.

Conclusions

The intervention is estimated to generate better health outcomes at lower costs, contributing to improving the efficiency of the public health system in Portugal.

Correction to the article "Excess Mortality Estimation During the COVID-19 Pandemic: Preliminary Data from Portugal", published on Acta Med Port 2020 Jun;33(6):376-383

Article published with errors: https://www.actamedicaportuguesa.com/revista/index.php/amp/article/view/13928On page 376, in Abstract, paragraph Results, where it reads: ”Despite the inherent uncertainty, it is safe to assume an observed excess mortality of 2400 to 4000 deaths. Excess mortality was associated with older age groups (over age 65).”It should read: “An excess mortality of 2400 to 4000 deaths was observed. Excess mortality was associated with older age groups (over age 65).”On page 376, in Abstract, paragraph Conclusion, where it reads: ”The excess mortality occurred between March 1 and April 22 was 3 to 5 fold higher than what can be explained by the official COVID-19 deaths.”It should read: “Despite the inherent uncertainty, the excess mortality occurred between March 1 and April 22 could be 3.5- to 5-fold higher than what can be explained by the official COVID-19 deaths.”On page 376, in Resumo, paragraph Conclusão, where it reads: “Da análise dos resultados é possível concluir que o excesso de mortalidade ocorrido entre 1 de março e 22 de abril foi 3 a 5 vezes superior ao explicado pelas mortes por COVID-19 reportadas oficialmente.”It should read: “Apesar da incerteza inerente, da análise dos resultados é possível concluir que o excesso de mortalidade ocorrido entre 1 de março e 22 de abril poderá ter sido 3,5 a 5 vezes superior ao explicado pelas mortes por COVID-19 reportadas oficialmente.”On page 377, last line of the first paragraph, where it reads: “If the lockdown had some protective effect on overall mortality, like summer holiday months seem to have, these effects may be observed some, if not all, age groups.”It should read: “If the lockdown had some protective effect on overall mortality, like summer holiday months seem to have, these effects may be observed in all age groups.”On page 377, section Results, third paragraph, last sentence where it reads: “Mortality in the younger age groups was, on average, below the proposed baselines, as hypothesized.”It should read: “Mortality in the younger age groups was, on average, lower than the proposed baselines as theorized.”On page 382, section Conclusion, last sentence, where it reads: “Overall, these results point towards an excess mortality that is associated with and that is 3 to 5-fold higher than the official COVID-19 mortality.” It should read: “Overall, these results point towards an excess mortality that is associated with and that could be 3.5- to 5-fold higher than the official COVID-19 mortality.” Artigo publicado com erros: https://www.actamedicaportuguesa.com/revista/index.php/amp/article/view/13928Na página 376, no Abstract, parágrafo Results, onde se lê: “Despite the inherent uncertainty, it is safe to assume an observed excess mortality of 2400 to 4000 deaths. Excess mortality was associated with older age groups (over age 65).”Deverá ler-se: “An excess mortality of 2400 to 4000 deaths was observed. Excess mortality was associated with older age groups (over age 65).”Na página 376, no Abstract, parágrafo Conclusion, onde se lê: “The excess mortality occurred between March 1 and April 22 was 3 to 5 fold higher than what can be explained by the official COVID-19 deaths."Deverá ler-se: “Despite the inherent uncertainty, the excess mortality occurred between March 1 and April 22 could be 3.5- to 5-fold higher than what can be explained by the official COVID-19 deaths.”Na página 376, no Resumo, parágrafo Conclusão, onde se lê: “Da análise dos resultados é possível concluir que o excesso de mortalidade ocorrido entre 1 de março e 22 de abril foi 3 a 5 vezes superior ao explicado pelas mortes por COVID-19 reportadas oficialmente.”Deverá ler-se: “Apesar da incerteza inerente, da análise dos resultados é possível concluir que o excesso de mortalidade ocorrido entre 1 de março e 22 de abril poderá ter sido 3,5 a 5 vezes superior ao explicado pelas mortes por COVID-19 reportadas oficialmente.”Na página 377, na última linha do primeiro parágrafo, onde se lê: “If the lockdown had some protective effect on overall mortality, like summer holiday months seem to have, these effects may be observed some, if not all, age groups.”Deverá ler-se: “If the lockdown had some protective effect onoverall mortality, like summer holiday months seem to have, these effects may be observed in all age groups.”Na página 377, secção Resultados, terceiro parágrafo última frase, onde se lê: “Mortality in the younger age groups was, on average, below the proposed baselines, as hypothesized.”Deverá ler-se: “Mortality in the younger age groups was, on average, lower than the proposed baselines as theorized.”Na página 382, secção Conclusion, última frase, onde se lê: “Overall, these results point towards an excess mortality that is associated with and that is 3 to 5-fold higher than the official COVID-19 mortality.”Deverá ler-se: “Overall, these results point towards an excess mortality that is associated with and that could be 3.5- to 5-fold higher than the official COVID-19 mortality.”

Excess Mortality Estimation During the COVID-19 Pandemic: Preliminary Data from Portugal

INTRODUCTION

Portugal is experiencing the effects of the COVID-19 pandemic since March 2020. All-causes mortality in Portugal increased during March and April 2020 compared to previous years, but this increase is not explained by COVID-19 reported deaths. The aim of this study was to analyze and consider other criteria for estimating excessive all-cause mortality during the early COVID-19 pandemic period.

MATERIAL AND METHODS

Public data was used to estimate excess mortality by age and region between March 1 and April 22, proposing baselines adjusted for the lockdown period.

RESULTS

An excess mortality of 2400 to 4000 deaths was observed. Excess mortality was associated with older age groups (over age 65) [corrected].

DISCUSSION

The data suggests a ternary explanation for early excess mortality: COVID-19, non-identified COVID-19 and decrease in access to healthcare. The estimates have implications in terms of communication of non-pharmaceutical actions, for research, and to healthcare professionals.

CONCLUSION

Despite the inherent uncertainty, the excess mortality occurred between March 1 and April 22 could be 3.5- to 5-fold higher than what can be explained by the official COVID-19 deaths [corrected].

Is olive oil good for you? A systematic review and meta-analysis on anti-inflammatory benefits from regular dietary intake

The prevalence of non-communicable diseases is rapidly increasing, and evidence shows that diet and lifestyle are key areas of intervention to decrease their burden. Olive oil is considered one of the key nutritional components responsible for the benefits of the Mediterranean diet, which is characterized by the use of olive oil in meals as the main source of fat; a high consumption of water, fruits, nuts, vegetables, legumes, whole grains, spices, and herbs; a moderate consumption of dairy products (mainly cheese and yogurt), fish, poultry, and red wine; and a reduced consumption of red meat and processed foods. The aim of this review was to summarize evidence from randomized controlled trials on the effect of regular dietary intake of olive oil on three inflammatory markers: C-reactive protein, interleukin-6, and tumor necrosis factor-α. Reviewed RCTs reveal beneficial effects of olive oil by reducing levels of inflammation markers. Olive oil taken on a regular basis can be a good dietary fat alternative, especially to manage IL-6. However, further research is required to clarify the effects of olive oil consumption on inflammation, comparing to other fats. Moreover, olive oil daily dosage, different time-lenght intervention and follow-up periods should be taken into consideration.

[Choosing Wisely Portugal - Wise Health Decisions]

n/a.

[Analysis of the Cochrane Review: Early Discharge Hospital at Home. Cochrane Database Syst Rev. 2017;6:CD000356.]

Hospital at home is a service that provides active treatment by healthcare professionals in the patient's home for a condition that otherwise would require acute hospital in-patient care. However, the clinical bene t of this intervention and its effect on health costs are not established. This Cochrane systematic review aimed to assess the effectiveness and costs of managing patients with hospital at home compared with inpatient hospital care. A systematic review of the literature was carried out by searching the following databases to 9 January 2017: Cochrane Effective Practice and Organization of Care Group (EPOC) register, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, CINAHL, EconLit and clinical trials registries. Thirty-two randomized trials (2 of which unpublished), including 4746 patients, were included. The present review provides insuf cient objective evidence of economic bene t (through a reduction in hospital length of stay) or improved health outcomes.

The place of DPP-4 inhibitors in the treatment algorithm of diabetes type 2: a systematic review of cost-effectiveness studies

OBJECTIVE

To conduct a systematic review of cost-effectiveness, cost-utility, and cost-benefit studies of DPP-4 inhibitors for diabetes treatment versus other antidiabetics.

METHODS

Three investigators searched the CRD York, Tufts CEA Registry, and MEDLINE databases through 2015. We reviewed all potentially relevant titles and abstracts, and screened full-text articles, according to inclusion criteria. We established a quality score for each study based on a 35-item list.

RESULTS

A total of 295 studies were identified, of which 20 were included. The average quality score was 0.720 on a 0-1 scale. All studies were performed in high- and middle-income countries, using a 3rd-party payer perspective and randomized clinical trials to measure effectiveness. Sitagliptin, saxagliptin and vildagliptin had an ICER below 25,000 €/QALY, as second-line and as add-ons to metformin, in comparison to sulfonylureas. When compared with sitagliptin, liraglutide (GLP-1 receptor agonist) had an ICER of up to 22,724 €/QALY for the 1.2-mg dosage, and up to 32,869 €/QALY for the 1.8-mg dosage. Insulin glargine was dominant when compared with sitagliptin.

CONCLUSIONS

According to the WHO threshold applied to the country and year of each study, DPP-4 inhibitors were highly cost-effective as second-line, as add-ons to metformin, in comparison with sulfonylureas. More recent therapies (GLP-1 receptor agonists and insulin glargine) were highly cost-effective in comparison to DPP-4 inhibitors. These results were obtained, however, on the basis of a limited number of studies, relying on the same few clinical trials, and financed by manufacturers. Further independent research is needed to confirm these findings.

Evidence-based hemorheology. Does it exist? Applying evidence from clinical studies to the individual patient

Clinicians are used to treat individual patients, and therefore may feel that clinical trials and systematic reviews do not give information for optimal treatment of the single patient.Evidence Based Medicine (EBM) is the integration of research evidence (from clinically relevant studies conducted using sound methodology) with clinical expertise (clinician's cumulated experience) and patient values (personal preferences and unique concerns and expectations).The practical steps of EBM include: 1) assess the patient, 2) ask the clinical question, 3) acquire the evidence, 4) critically appraise the evidence, 5) apply the results to the patient and 6) self-evaluate one's practice.Clinical studies in clinical hemorheology include - among other - interventions in vascular medicine: coronary disease, stroke, peripheral vascular disease, venous insufficiency and thrombosis, etc.Of these, we will present some practical steps on how to apply therapy results of stroke studies to the individual patient (this addresses step number 5 in the previous definition of EBM practice).We will do this by discussing the differences between internal and external validity of clinical trials, and defining the importance of baseline risks to choose therapy using the data from the best and most useful studies available. In the end, clinicians will understand how to use evidence effectively.

Análise da Revisão Cochrane: Administração Suplementar de Vitamina D para Prevenção de Cancro em Adultos. Cochrane Database Syst Rev. 2014, 6:CD007469

Vitamin D has been mentioned in the literature has a potentially important agent for preventing the development of tumors, namely breast, colon, prostate and ovary tumors. However, the currently available evidence on the subject is contradictory and inconclusive. In this Cochrane systematic review, patients taking supplemental vitamin D on its various forms (cholecalciferol, ergocalciferol, alfacalcidol or calcitriol), regardless the dose, duration and route of administration, were compared with placebo, healthy adults without any intervention or adults with a disease in a stable phase, non-related with vitamin D metabolism. The results showed that currently, there is no firm evidence that vitamin D supplementation increases or decreases the risk of cancer occurrence, mainly in elderly community- dwelling women. Though at risk of type I errors due to small samples and substantial dropout of participants during the trials, the administration of supplemental cholecalciferol led to a 12% (CI 95%: 2 a 22%) decreased in cancer mortality, while the administration of supplemental vitamin D decreased all-cause mortality by 7% (CI 95%: 2 a 12%). The combined administration of supplements of cholecalciferol and calcium induced an increased incidence of nephrolithiasis.<br /><strong>Keywords:</strong> Adult; Randomized Controlled Trials as Topic; Neoplasms/prevention and control; Systematic Reviews; Vitamin D.

Análise da Revisão Cochrane: Inibidores da Trombina versus Antagonistas da Vitamina K na Prevenção do Acidente Vascular Cerebral em Doentes com Fibrilhação Auricular Não-Reumática. Cochrane Database Syst Rev. 2014,3:CD009893

Ischemic stroke is one of the most important complications of lone (non-valvular) atrial fibrillation. Its prevention is usually accomplished through oral anticoagulation. Until a few years ago warfarin was the most used agent, but recently two new pharmacologic classes have been introduced for stroke prevention in these patients: oral direct thrombin inhibitors (dabigatran and ximelagatran) and oral factor Xa inhibitors (rivaroxaban, apixaban and edoxaban). In this systematic review, oral direct thrombin inhibitors were compared with warfarin for efficacy and safety. The results indicate that there is no difference in terms of efficacy (except dabigatran 150 mg BID). Oral direct thrombin inhibitors presented less hemorrhages but increased treatment withdrawal due to adverse side-effects (the authors performed post-hoc analyses excluding ximelagatran because this drug was withdrawn from the market owing to safety concerns). There was no difference in terms of mortality between the agents.

[Analysis of the Cochrane Review: Direct thrombin inhibitors versus vitamin K antagonists for preventing cerebral or systemic embolism in people with non-valvular atrial fibrillation. Cochrane Database Syst Rev. 2014,3:CD009893]

Ischemic stroke is one of the most important complications of lone (non-valvular) atrial fibrillation. Its prevention is usually accomplished through oral anticoagulation. Until a few years ago warfarin was the most used agent, but recently two new pharmacologic classes have been introduced for stroke prevention in these patients: oral direct thrombin inhibitors (dabigatran and ximelagatran) and oral factor Xa inhibitors (rivaroxaban, apixaban and edoxaban). In this systematic review, oral direct thrombin inhibitors were compared with warfarin for efficacy and safety. The results indicate that there is no difference in terms of efficacy (except dabigatran 150 mg BID). Oral direct thrombin inhibitors presented less hemorrhages but increased treatment withdrawal due to adverse side-effects (the authors performed post-hoc analyses excluding ximelagatran because this drug was withdrawn from the market owing to safety concerns). There was no difference in terms of mortality between the agents.

[Analysis of the Cochrane review: Multimedia educational interventions for consumers about prescribed and over-the-counter medications. Cochrane Database of Systematic Reviews 2013;4:CD008416]

Understanding of the relevant information is especially important in the area of drug treatment, to guarantee an appropriate and rational use of medications by patients. The relevant information must be delivered in a way that patients understand all aspects of the treatment regimen they are taking. In this systematic review the authors analyzed a set of studies on the effectiveness of multimedia educational interventions about medications (prescribed or not) in patients of all ages, concluding that the aforementioned interventions are more effective than usual care (non-standardized education provided by health professionals as part of usual clinical care) or no education.

Análise da Revisão Cochrane: Antibioticoterapia na Otite Média Aguda da Criança. Cochrane Database Syst Rev. 2013;1:CD000219

Acute otitis media is one of the most common infections in children and one of the leading causes for antibiotic prescription. In this paper, we assess and comment the Cochrane systematic review 'Antibiotics for acute otitis media in children', which aimed at assessing the efficacy and safety of antibiotics for acute otitis media in children and identifying subgroups of children who might benefit more than others from antibiotic treatment. This review showed spontaneous resolution of acute otitis media in most children (82%) and a favorable but modest effect of antibiotics, namely in pain control (number needed to treat to benefit: 20), reduction of tympanic membrane perforations and reduction of contralateral acute otitis media. Adverse effects such as vomiting, diarrhea or rash were more common in the antibiotic group (number needed to treat to harm: 14). Thus, for most children, an expectant observational approach during 48-72h without immediate antibiotic prescription seems justified. An additional meta-analysis found that antibiotics appear to be most useful in children with both acute otitis media and otorrhoea and children under two years of age with bilateral acute otitis media.

[Analysis of the Cochrane Review: Antibiotics for acute otitis media in children. Cochrane Database Syst Rev. 2013;1:CD000219]

Acute otitis media is one of the most common infections in children and one of the leading causes for antibiotic prescription. In this paper, we assess and comment the Cochrane systematic review 'Antibiotics for acute otitis media in children', which aimed at assessing the efficacy and safety of antibiotics for acute otitis media in children and identifying subgroups of children who might benefit more than others from antibiotic treatment. This review showed spontaneous resolution of acute otitis media in most children (82%) and a favorable but modest effect of antibiotics, namely in pain control (number needed to treat to benefit: 20), reduction of tympanic membrane perforations and reduction of contralateral acute otitis media. Adverse effects such as vomiting, diarrhea or rash were more common in the antibiotic group (number needed to treat to harm: 14). Thus, for most children, an expectant observational approach during 48-72h without immediate antibiotic prescription seems justified. An additional meta-analysis found that antibiotics appear to be most useful in children with both acute otitis media and otorrhoea and children under two years of age with bilateral acute otitis media.

Resumo da Revisão Cochrane

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Prescrição Off-Label: Análise Científica tendo como Exemplo a Utilização de Bevacizumab em Oftalmologia

Off-label prescribing poses specific technical/scientific, professional and ethical problems. In this study we carry out a technical and scientific analysis of the off-label prescribing using a current, clinical and economically relevant example: the paradigmatic case of the use of bevacizumab in ophthalmologic pathologies for which it has no formal indication. We conducted a systematic review of the literature on the efficacy and safety of this drug, as well as ranibizumab - which has approved ophthalmologic indications, in order to qualitatively analyze the available evidence on the two interventions. This is a typical case for technical and scientific analysis of the off-label prescribing problems. According to the results of the systematic review, the use of bevacizumab in this context has in fact scientific evidence of appreciable size, including clinical trials head-to-head with ranibizumab. However, the identified safety issues raise the question of the use of this drug in ophthalmologic pathologies. The different players involved in the treatment decisions (physicians, patients and institutional decision makers) should be adequately informed about the existing evidence that supports off-label prescribing which, by definition, must always be on an exceptional basis and properly justified.

A Acta Médica Portuguesa e a Cochrane Collaboration

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[Off-label prescribing: scientific analysis taking the use of bevacizumab in ophthalmology as an example]

Off-label prescribing poses specific technical/scientific, professional and ethical problems. In this study we carry out a technical and scientific analysis of the off-label prescribing using a current, clinical and economically relevant example: the paradigmatic case of the use of bevacizumab in ophthalmologic pathologies for which it has no formal indication. We conducted a systematic review of the literature on the efficacy and safety of this drug, as well as ranibizumab - which has approved ophthalmologic indications, in order to qualitatively analyze the available evidence on the two interventions. This is a typical case for technical and scientific analysis of the off-label prescribing problems. According to the results of the systematic review, the use of bevacizumab in this context has in fact scientific evidence of appreciable size, including clinical trials head-to-head with ranibizumab. However, the identified safety issues raise the question of the use of this drug in ophthalmologic pathologies. The different players involved in the treatment decisions (physicians, patients and institutional decision makers) should be adequately informed about the existing evidence that supports off-label prescribing which, by definition, must always be on an exceptional basis and properly justified.